When I was in practice in the 1980s, I didn’t give much thought to the number of health visitors nationally – just my own caseload. We visited all ages, in theory, but mostly under-fives. There would be around 40 to 50 new births per year, per health visitor – so up to 250 children per caseload, which is still the current recommendation. I loved the variety and autonomy, meeting and getting to know all the families, running groups for whatever seemed to be needed, linking with community activities and pre-schools, and staying in touch with local GPs where we were based, and with other health and care staff.
We were the tail end of the group known as the ‘new breed of health visitors’, with a training curriculum that started in the 1960s and lasted until the 1990s. We understood the importance of relationships and basic courtesy – don’t enter until invited, don’t sit unless you’re asked, be respectful – and don’t presume you know. Building relationships, listening, supporting – and noticing. Spending a moment longer to allow time for that uncertain ‘shall-I-ask-it’ question; arranging a home visit for a mother hesitant to talk in a busy clinic. Knowing what to suggest – and when. Feeding, weaning, toilet training, teething, talking and walking – all basic stuff, but so important. Understanding that some families needed more support than others, but that all new mothers and babies are vulnerable. Visiting more often when that was needed, as well.
The wellbeing of the whole family matters, of course, but infants and pre-school children can be invisible to the outside world. Health visitors are privileged to be allowed into people’s homes and have a responsibility to watch out for infants whose parents cannot, or are not in a position to, provide them with the nurturing care they need. It remains shocking that at least one child a week dies at the hands of their parents in this country – most of them are under the age of one year.
This year, hidden from the outside world, some 200,000 new babies were brought into a strangely different world from the one their parents envisaged at the start of each pregnancy. During the most restrictive period of lockdown, births took place with limited or no family support, and without the usual health visiting and children’s services to see them through. What happened to those invisible children throughout the coronavirus lockdown, when many health visitors were seconded into hospitals? Concern about those children led me to check the monthly NHS workforce statistics – and to discover the disappearing health visitors.
I’d started tracking the workforce when I was a PhD student – driven to research by Mrs Thatcher’s cost-of-everything, value-of-nothing NHS reforms. That’s how I know there were 10,480 health visitors in England in 1990. That seemed like a low point at the time, leading to much anger and soul searching across the profession about how we could reduce workloads, whilst continuing to provide a safe and effective service. The number of NHS health visitors in post continued to slide until a national programme boosted their numbers back to a high point of 10,256 in May 2015. Five years on, health visiting numbers have fallen by some 35 per cent, to 6,672 in May 2020, their lowest point for decades. For comparison, the number of NHS staff overall has gone up by some 10 per cent since 1990. Some still regard this increase as too small, as the UK population has grown by around ten million in the same period – an increase of about 17 per cent.
Since I entered the profession 40 years ago, a huge amount of scientific research has confirmed what many of us always suspected: infancy is a crucial period for later health, wellbeing and life chances. The ‘first 1000 days’ (conception to age two) are crucial for babies’ brain development, which affects their later mental health and cognition, including the ability to learn and organise thinking. Babies’ brains develop best when they have a loving, responsive carer – usually Mum – who sees that they’re kept warm (or cool, in heatwaves), secure and properly fed. It sounds so easy, but that assumes someone is caring for the carer and that all is well in the parental home. Enabling the best start in life is a noble government aim, but without resources to achieve it, it’s meaningless.
As many as one in five new mothers experience mental health problems in ‘normal times’, but social isolation and other stresses have added immeasurably to the strain of having a ‘lockdown baby’. Whilst a minority of new parents thrived during this period, when asked in a survey of their experiences, nine in ten reported feeling more anxious. A quarter cited mental health problems as their main concern. Three in ten felt confident that they could access mental health support if they needed it, but only one in ten reported seeing a health visitor face to face during lockdown.
At the end of July, a UCL survey reported on the impact of seconding health visitors into hospitals at the start of lockdown. Some managers had refused to relocate their staff at all. Around 60 per cent of local services seconded some staff, with 10 per cent moving up to half of their health visitors into hospitals. Colleagues remaining in post had to expand their, already large, caseloads by as many as 200 additional children. Unsurprisingly, the health visitors were conscious of the shortcomings of their service, expressing concerns about vulnerable parents and children, and the possibility that they were missing important issues. Domestic abuse, child safeguarding and neglect were high on health visitors’ list of concerns, along with worries that they might miss delayed child development, be unable to support new parents with mental health worries or to continue breast feeding. Missing any of these issues can lead to life-long consequences for the new infants and their family.
The long-term decline in the number of health visitors is often attributed to a perceived need to reduce health service costs. There is a focus on urgency in health care as well: an ambulance at the bottom of the cliff is always a higher priority than a fence at the top. Quite apart from the human cost in terms of distress and avoidable suffering, this acute outlook is expensive in the long term. Economists have produced some eye-watering figures. They calculate that the lifetime cost for each victim of child maltreatment is likely to be around £89,390; or if the child is killed, it costs society £940,758 for each child, including the cost of health care and lost productivity. The total lifetime costs for perinatal depression have been estimated at £75,728 per woman. And if UK mothers who are exclusively breast feeding at one week were supported to continue breast feeding until four months, if they wish, the resulting reduction in the incidence of childhood infectious diseases could save at least £11m annually, Health visiting services are not cheap, but the costs of prevention pale in comparison to the enormous sums in just these three examples.
Benjamin Franklin is reputed to have said that ‘an ounce of prevention is worth a pound of cure’. We can expect to see soaring costs, and heart-breaking tales of suffering, when we finally catch up with these lockdown babies and their unsupported families. Hopefully, health visitors will still be there, ready to help pick up some of the pieces.